Parenchymal Mass Research Articles

Functional Comparison of Renal Tumor Enucleation Versus Standard Partial Nephrectomy

BackgroundTumor enucleation (TE) optimizes parenchymal preservation and could yield better function than standard partial nephrectomy (SPN), although data on this are conflicting. ObjectiveTo compare functional outcomes for TE and SPN strategies. Design, setting, and participantsPatients managed with partial nephrectomy (PN) with necessary data for analysis of preservation of ipsilateral parenchymal mass (IPM) and global glomerular filtration rate (GFR) from two centers were included. All studies were required <2 mo before and 3–12 mo after surgery. Patients with a solitary kidney or multifocal tumors were excluded. InterventionPartial nephrectomy. Outcome measurements and statistical analysisVascularized IPM was estimated from contrast-enhanced CT scans preoperatively and postoperatively. Serum creatinine-based estimates of global GFR were also obtained in the same timeframes. Univariable and multivariable linear regression evaluated factors associated with new-baseline global GFR. Results/limitationsAnalysis included 71 TE and 373 SPN cases. The median preoperative global GFR was comparable for TE and SPN (75 vs 78ml/min/1.73m2; p=0.6). The median tumor size was 3.0cm for TE and 3.3cm for SPN (p=0.03). The median RENAL score was 7 in both cohorts. For TE, warm ischemia and zero ischemia were used in 51% and 49% of cases, respectively. For SPN, warm ischemia and cold ischemia were used in 72% and 28% of patients, respectively. Capsular closure was performed in 46% of TE and 100% of SPN cases (p<0.001). Positive margins were found in 8.5% of TE and 4.8% of SPN patients (p=0.2). The median vascularized IPM preserved was 95% (interquartile range [IQR] 91–100%) for TE and 84% (IQR 76–92%) for SPN (p<0.001). The median global GFR preserved was 101%(IQR 93–111%) and 89% (IQR 81–96%) for TE and SPN, respectively (p<0.001). On multivariable analysis, resection strategy, preoperative GFR, and vascularized IPM preserved were all significantly associated (p<0.001) with new-baseline global GFR. Limitations include the retrospective design and the lack of resection outcome data. ConclusionsOur analysis suggests that TE has potential for maximum IPM preservation compared to SPN and may provide optimized functional recovery. Further investigation will be required to evaluate the clinical significance of these findings. Patient summaryTumor enucleation for kidney cancer involves dissection along the tumor capsule and optimally preserves normal kidney tissue, which may lead to better functional recovery. The importance of this approach in various clinical settings will require further investigation.

Devascularized Parenchymal Mass Associated with Partial Nephrectomy: Predictive Factors and Impact on Functional Recovery

Parenchymal mass loss is the predominant factor associated with functional outcomes after partial nephrectomy. It is primarily due to excised and/or devascularized parenchymal mass. We evaluated the importance of excised and devascularized parenchymal mass relative to functional recovery after partial nephrectomy. In 168 patients who underwent partial nephrectomy the necessary studies were done to determine excised and devascularized parenchymal mass, and evaluate parenchymal mass changes and functional loss of the operated kidney. Parenchymal mass loss in the ipsilateral kidney was measured on contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy. Excised parenchymal mass was estimated by subtracting tumor volume from specimen volume. Devascularized parenchymal mass was defined as total parenchymal mass loss minus excised parenchymal mass. We used the Pearson correlation to evaluate relationships between glomerular filtration rate preservation and parenchymal mass loss. Multivariable analysis was done to assess factors associated with devascularized parenchymal mass. Median tumor size was 3.4 cm and median R.E.N.A.L. (radius, exophytic/endophytic tumor properties, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score was 7. Warm and cold ischemia was used in 100 and 68 patients, respectively. Median excised parenchymal and devascularized parenchymal mass was 9and 16 cm3, respectively (p <0.001). Total parenchymal mass loss and devascularized parenchymal mass were associated strongly with glomerular filtration rate preservation in the operated kidney (each r ≥0.55, p <0.001). However, excised parenchymal mass was only weakly associated with functional outcomes (r = 0.23). The preoperative glomerular filtration rate and endophytic status were associated with devascularized parenchymal mass on multivariable analysis. To our knowledge we report the first study to specifically evaluate the relative contributions of devascularized and excised parenchymal mass to functional recovery after partial nephrectomy. Our study suggests that devascularized parenchymal mass has more impact, whichmay have implications regarding surgical technique. Prospective study is required tofurther evaluate the relative contributions of excised and devascularized parenchymal mass in various settings.

Effects of preweaning nutrient intake in the developing mammary parenchymal tissue

Historically, mammary gland growth has been considered isometric the first 2 mo of life and then allometric until peripuberty. However, recent work indicated that the mammary gland might be responsive to nutrient intake preweaning. The objectives of this study were to describe the effects of nutrient intake preweaning on mammary gland development and to investigate cell specific proliferation during this phase of development. Twelve dairy heifer calves were fed either a fixed amount of milk replacer (MR; control, n = 6) or an amount of MR adjusted for BW (enhanced, n = 6). Control calves received a constant amount of a 28% crude protein, 15% fat milk MR per day that was equivalent to 2.8 Mcal of metabolizable energy intake per day; enhanced calves received 0.3 Mcal of metabolizable energy intake per kilogram of metabolic body weight (from 4.2 to 8.4 Mcal of metabolizable energy intake per day). All calves had constant access to water and a 22% crude protein commercial calf starter. Calves were killed at 54 ± 2 d. Control calves consumed 32.6 ± 2.4 kg of MR and 6.7 ± 0.5 kg of calf starter per calf, whereas the enhanced calves consumed 69.5 ± 2.4 kg of MR and 1.9 ± 0.5 kg of calf starter per calf over the 54-d period. Further, to evaluate putative stem cell proliferation, BrdU (5-bromo-2'-deoxyuridine; 5 mg/kg) was injected intramuscularly once per day between 12 to 15 d and again once per day between 24 to 27 d of life. Initial and final body weight for the control and enhanced treatments were 39.2, 61.0, 39.7, and 83.2 kg, respectively. At euthanasia, weights of liver, kidneys, pancreas, whole skinned mammary gland, and mammary parenchyma were measured. The growth rate of each organ was calculated using the concept of allometry as the difference in the change in organ weight as a percentage of body weight. The mammary glands of calves fed the enhanced diet were significantly heavier at euthanasia; when mammary parenchymal weight was analyzed, enhanced calves had 5.9 times greater mammary parenchymal mass, indicating the mammary gland was responsive to nutrient intake before weaning. Allometric growth of the mammary gland was initiated preweaning in the calves fed the enhanced treatment. Further characterization of mammary cells that retained BrdU label revealed no significant differences among the tissue slices analyzed between treatments; however, as calves fed the enhanced diet had more mammary parenchymal mass, if the number of label-retaining cells per counted slide were similar between treatments then the enhanced calves had a larger total population of putative mammary stem cells present in the mammary gland.

The significance of predictable traumatic area by renorrhaphy in the prediction of postoperative ipsilateral renal function.

IntroductionTo determine the relationship between the actual renal function loss and volume loss in robot-assisted partial nephrectomy (RAPN) using a novel three-dimensional volume analyzer.Material and methodsWe respectively evaluated the medical records of 23 consecutive patients who underwent RAPN between January 2012 and March 2016 and the data on their kidney function and parenchymal mass specific to the operated kidney. Parenchymal volume was measured by computerized tomography and reconstructed with a Synapse Vincent volumetric analyzer. Using this system, we predicted the renal vascular territory and other trauma areas involved in renorrhaphy. All measurements were taken within 3 and 6 months pre- and postoperatively, respectively.RESULTSThe actual postoperative renal parenchymal volume was significantly correlated with the virtual predicted residual renal volume excluding the tumor and resected margin (r = 0.435, p <0.05). The ratio of split estimated glomerular filtration rate (eGFR) postoperative/preoperative) was significantly correlated with the virtual predicted residual renal volume excluding the resected margin and the traumatic area by renorrhaphy (r = 0.401, p <0.05).ConclusionsWhen predicting the reduction of renal function of the diseased side following partial nephrectomy, adding the extent of the area traumatized by renorrhaphy might be useful for predicting the postoperative split renal function of the affected kidney.

Pharmacognostical and Phytochemical Studies of Helleborus niger L Root.

Background:Helleborus niger L (Ranunculaceae) is used Ayurvedic and Unani systems and other herbal medicine systems. The roots of H. niger have a good medicinal value.Aims:To conduct a pharmacognostical and phytochemical study of H. niger.Materials and Methods:The pharmacognostical studies on roots including parameters such as taxonomical, macroscopic, microscopic characters, physico-chemical, ultra-violet analysis and phytochemical studies are established.Results:Macroscopically, the roots are brownish-black in colour, cylindrical in shape, feeble odour, slightly acrid taste with irregularly branched. Microscopically the root showed the presence of epidermis, air-chambers, fissure periderm, periderm, inner cortex, pith, phloem, xylem, vessels and xylem vessels. Microscopic examination of the powder showed the presence of parenchyma cells, parenchyma mass, periderm, cell inclusion, laticifer, lateral wall pith, perforation, xylem bundle and xylem elements. Ultra-violet and ordinary light analyses with different reagents were conducted to identify the drug in powder form. Physico-chemical evaluation established, Ash values - Total, acid insoluble, water soluble and sulphated ash values were 7.3%, 4.1%, 3.7% and 5.2%, respectively. Extractive values - Alcohol soluble, water soluble and ether soluble extractive values were 22.8%, 7.4% and 5.6%, respectively. Loss on drying was 3.3%. Preliminary phytochemical screening showed the presence of carbohydrate, glycoside, saponins, flavonoid, phytosterols, tannins and phenolic compounds.Conclusions:The results of the study can serve as a valuable resource of pharmacognostic and phytochemical information. This will serve as appropriate, standards for discovery of this plant material in future investigations and applications and also contribute towards establishing pharmacopoeial standards.

超声造影诊断脾脏多发转移瘤1例

报告一例经超声造影诊断的脾脏多发转移瘤病例。该患者以糖尿病入院，腹部彩超检查诊断脾脏多发实质性占位(转移瘤？)，经超声造影诊断符合脾脏多发转移瘤表现。查找原发病灶，胸腹部增强CT诊断：右肺周围型肺癌；脾多发低密度影，考虑脾转移瘤。超声造影作为一种新技术，无放射性、无肝肾毒性，简便、快捷，应用于脾脏占位性病变的诊断及鉴别诊断，能为临床提供重要诊断依据。 A case of multiple splenic metastasis diagnosed by contrast-enhanced ultrasound was reported. The patient was admitted with diabetes mellitus, presenting multiple parenchymal masses of spleen (metastatic tumor?) in abdominal ultrasonography, and the diagnosis of multiple metastatic tumors of the spleen was confirmed by contrast-enhanced ultrasonography (CEUS). The primary lesion of peripheral lung cancer of the right lung with splenic metastasis presenting multiple low density shadows in the spleen was diagnosed by chest and abdominal enhanced CT. As a new technique, CEUS provides important diagnostic evidence in the diagnosis and differentiation of splenic occupying lesions with advantages of non-radioactivity, no toxicity of liver and kidney, convenient and fast.

Mediastinoscopy in Assessing Mediastinal Lymphadenopathy and Lung Disease

Background: Mediastinoscopy is the gold standard procedure for the pathological staging and diagnosis of mediastinal diseases. The aim of the study is to describe the significance of anterior cervical Mediastinoscopy in evaluating patients with mediastinal lymphadenopathy and lung parenchymal disease. Material and Methods: From January 2014 until June 2017 we conducted a retrospective study of 52 consecutive patients with mediastinal lymphadenopathy and lung parenchymal disease who underwent anterior cervical Mediastinoscopy. The main indications for cervical Mediastinoscopy were isolated mediastinal lymphadenopathy, undetermined lung mass with mediastinal lymphadenopathy, and the clinical staging of patients with lung cancer. Results: The study subjects consisted of 37 men and 15 women, aged 13 to 87 (mean age 50.8). Eight patients had mediastinoscopy for staging lung cancer, 27 patients had mediastinoscopy to diagnose isolated mediastinal lymphadenopathy, and 17 patients had mediastinoscopy for an undetermined lung parenchymal mass. Among the patients with isolated mediastinal lymphadenopathy, sarcoidosis was diagnosed in 6, tuberculosis in 9, reactive lymph nodes in 4, metastasis in 5 and lymphoma in 3. Lymph node metastasis (N2, N3) was found in 5 patients with lung cancer. There was no surgical-related mortality or morbidity. Conclusions: Mediastinoscopy is a safe and reliable procedure in diagnosing mediastinal diseases and is still the first choice among the investigative modalities in the clinical staging of bronchogenic carcinoma.

Brain Metastases in a Patient with Ovarian Cancer

Brain metastases are associated with a poor prognosis. Depending on the patient’s age, functional status, extent of systemic disease, and number of metastases. We report a case of 22-year-old female who presented with 2 months history of headache and vomiting and 1 day history of not communicating, neck stiffness, and generalized body weakness. Patient has been unwell for 2 months after she had collapsed at school 2 months prior complaining of severe headache, she allegedly stroked one month prior with left sided weakness. No history of trauma and seizures but had history of falling and remaining unconscious for unspecified period of time. No history of chronic illness and no family history of malignancies. Brain CT scan and MRI documented multiple lobulated irregularly enhancing brain parenchymal mass lesions of variable sizes, patient was taken to theatre and burr hole for brain tumor biopsy was done and specimen taken for histology which confirmed metastatic carcinoma and the tumor immunoreacted negatively to TTF1 and positively to CK7. Treatment of brain metastasis has evolved over the years from WBRT only for most patients to multimodal therapy including surgical resection, if feasible, followed by Whole brain Radiotherapy (WBRT) and/or chemotherapy.

The outcome of early decompressive craniectomy of rapidly evolving cerebral parenchymatous mass lesion: vascular or trauma

The outcome of early decompressive craniectomy of rapidly evolving cerebral parenchymatous mass lesion: vascular or trauma

Excised Parenchymal Mass During Partial Nephrectomy: Functional Implications

To evaluate whether excised parenchymal mass (EPM) during partial nephrectomy (PN) correlates with functional decline and can serve as a surrogate for functional outcomes. All 215 patients managed with PN for unifocal renal mass with necessary studies to determine EPM and percent glomerular filtration rate (GFR) and parenchymal mass preserved (both global and specific to the operated kidney) were analyzed. EPM was estimated from the pathologic specimen by subtracting the tumor mass from the specimen mass, with both calculated using the elliptical formula. Vascularized parenchymal mass preserved was measured from computed tomography scans obtained <2 months prior and 3-12 months after surgery. All functional analyses were required to be within the same time frames, and patients with a contralateral kidney were also required to have nuclear renal scans. The median tumor size was 3.5 cm and the median R.E.N.A.L. was 7. Warm and cold ischemia were utilized in 123 and 92 patients, respectively (median ischemia time = 23 minutes). The median global GFR preserved was 89%, the median total parenchymal mass preserved was 93%, and the median estimated EPM was 16 cm3. Whereas percent parenchymal mass preserved correlated strongly with global and ipsilateral GFR preserved (both P < .001), EPM failed to correlate with functional outcomes on both univariable and multivariable analyses. Our data suggest that parenchymal mass preserved with standard PN by experienced surgeons associates strongly with function preserved, whereas EPM fails to correlate with functional outcomes. Further study of the functional impact of EPM in other circumstances will be required, such as enucleation or PN performed by less-experienced surgeons.

Functional Implications of Renal Tumor Enucleation Relative to Standard Partial Nephrectomy

To compare the surgical precision for optimizing nephron-mass preservation of tumor enucleation (TE) vs standard partial nephrectomy (SPN), with primary focus on functional outcomes. TE is presumed to optimize preservation of parenchymal mass and function but this has not yet been rigorously studied and quantified. Robotic partial nephrectomy patients who had appropriate pre- and postoperative studies for analysis of parenchymal mass preservation specific to the operated kidney were included. Computed tomography or magnetic resonance imaging and estimated glomerular filtration rate were required to be <2 months prior and 4-12 months after surgery. Parenchymal mass preservation and surgical precision were estimated for each technique, with precision defined as actual postoperative parenchymal volume or predicted postoperative parenchymal volume, presuming loss of a 5 mm rim of parenchyma associated with tumor excision and reconstruction. Analysis included 57 TE and 53 SPN. Median age, body mass index, and tumor size were comparable. Percent parenchymal mass preserved in the operated kidney with TE was 96% (interquartile range [IQR] = 90-100) vs 89% (IQR = 83-96) for SPN (P = .003). Precision of excision or reconstruction was 101% (IQR = 96-105) for TE vs 94% (IQR = 88-100) for SPN (P < .001). On multivariable analysis, only TE correlated with improved surgical precision (coefficient = 6.7, 95% confidence interval = 1.6-11.8, P = .01). Although preservation of global renal function also favored TE, the differences were marginal (96% vs 93%), and statistical significance was not observed (P = .2). Our analysis, which specifically focuses on the functional implications of TE, demonstrates that TE maximally spares normal parenchyma compared to SPN. Thus far, functional differences remain marginal and not statistically significant. Clinical significance of these findings in various clinical settings will require further investigation.

Acute Ipsilateral Renal Dysfunction after Partial Nephrectomy in Patients with a Contralateral Kidney: Spectrum Score to Unmask Ischemic Injury

BackgroundAcute ischemic injury in the operated kidney after partial nephrectomy (PN) is often masked by a functional contralateral kidney; however, there is no practical method to assess this and its prognostic significance has not been defined. ObjectiveWe propose a spectrum score to reflect the degree of ischemic insult in the ipsilateral kidney and study its relationship to subsequent functional recovery. Design, setting, and participantsFrom 2007 to 2014, 243 patients with a functional contralateral kidney underwent PN with necessary studies for detailed analysis of function and parenchymal mass before and after surgery in the ipsilateral kidney. Based on split function and percent parenchymal mass preserved in the ipsilateral kidney, we determined: serum creatinine (SCr)ideal-peak: expected peak SCr presuming no ischemic injury; and SCrworstcase-peak: expected peak SCr presuming temporary complete nonfunction of the ipsilateral kidney. The acute ipsilateral renal dysfunction spectrum score was defined: (observed peak SCr – SCrideal-peak)/(SCrworstcase-peak – SCrideal-peak). Subsequent functional recovery was defined: (percent function preserved)/(percent mass saved). InterventionPN. Outcome measurements and statistical analysisFactors associated with spectrum score and relationship between spectrum score and subsequent functional recovery were evaluated by linear regression. Results and limitationsMedian duration of warm ischemia (n=152) was 21min (interquartile range [IQR] = 15–27) and hypothermia (n=91) 26min (IQR=23–30). Median parenchymal mass preservation was 83% (IQR=74–91%). Warm ischemia and longer ischemia duration associated with higher spectrum score (both p<0.05). Increased spectrum score (<25%, 25–50%, 50–75%, and >75% quartiles) had decreased functional recovery (98%, 94%, 90%, and 89%, respectively, p<0.001). However, this trend was not observed in the hypothermia cohort. On multivariable analysis spectrum score and ischemia type significantly associated with functional recovery (both p<0.01), while age and comorbidities failed to associate (p=0.3–0.7). ConclusionsAcute ipsilateral renal dysfunction spectrum score unmasks the degree of ischemic insult in the operated kidney after PN and associates with functional recovery. While increased spectrum score associates with suboptimal recovery, even patients with a high spectrum score reached 89–90% recovery. Patient summaryAcute functional decline after partial nephrectomy is difficult to evaluate in patients with two kidneys, but a proposed spectrum score can be used to evaluate this. Increased spectrum score reflects increased ischemia and may impact the functional recovery of the kidney.

Preoperative Prediction and Postoperative Surgeon Assessment of Volume Preservation Associated With Partial Nephrectomy: Comparison With Measured Volume Preservation

To evaluate whether surgeons can predict the percent parenchymal mass that will be preserved by partial nephrectomy (PN) based on preoperative imaging, which could have potential utility for preoperative surgical planning and patient counseling. The proportion of preserved viable parenchyma following PN is the primary determinant of functional recovery. However, direct measurement of parenchymal volume preservation (VP) can be complex and time consuming. For patients managed with PN at our institution (2007-2014), we randomly selected 45 with a third in each of low, intermediate, or high R.E.N.A.L. complexity groups. All patients had recorded postoperative surgeon assessment of volume preservation (SAVP) and measured VP based on preoperative or postoperative computed tomography. Nine clinical providers predicted VP based solely on review of preoperative imaging while blinded to SAVP and measured VP. Clinical experience of the providers ranged from medical students to experienced urologic surgeons. Median age was 66 years, median tumor size was 4.0 cm, and median R.E.N.A.L. was 8. Median measured VP was 81% (interquartile range of 74-89%). Preoperative prediction of VP correlated poorly with measured VP among the different surgeons (mean correlation coefficient, R = 0.34, range = 0.24-0.40). Surgeon experience provided minimal incremental improvement. Correlation between R.E.N.A.L. and measured VP was also marginal (R = 0.43). In contrast, correlation between postoperative SAVP and measured VP was much more robust (R = 0.75, P <.001). Preoperative prediction of VP and R.E.N.A.L. score correlated poorly with measured VP for patients managed with PN. In contrast, postoperative SAVP provided a relatively reliable estimate of VP, and should be considered an acceptable substitute in most clinical circumstances.

PD29-11 SURVIVAL OUTCOMES FOR LOCALIZED RENAL CELL CARCINOMA ACCORDING TO TUMOR LOCATION AND OPERATION METHOD (RADICAL VERSUS PARTIAL NEPHRECTOMY): A PROPENSITY MATCHED ANALYSIS

INTRODUCTION AND OBJECTIVES: Acute increase of serum creatinine (SCr) after partial nephrectomy (PN) is primarily due to parenchymal mass reduction or ischemia, however only ischemia can impact subsequent functional recovery. In the current study, we evaluate etiologies of acute kidney injury (AKI) after PN and their prognostic significance. METHODS: From 2007-2014, 83 solitary kidneys managed with PN had necessary studies for detailed analysis of function and parenchymal mass before/after surgery. AKI was classified by RIFLE (Risk/Injury/Failure/Loss/Endstage) defined by either standard criteria (comparison to preoperative SCr) or proposed criteria (comparison to projected postoperative SCr based on parenchymal mass reduction). Subsequent recovery was defined as percent function preserved normalized by percent mass saved. Predictive factors for AKI were evaluated by logistic regression. Relationship between AKI grade and subsequent functional recovery was assessed by linear regression. RESULTS: Median duration of warm ischemia (n1⁄439) was 20 minutes and hypothermia (n1⁄444) 29 minutes. Median parenchymal mass reduction was 11%. AKI occurred in 45 patients based on standard criteria and 38 based on proposed criteria, and reflected injury/failure (grade1⁄42/3) in 23 and 16 patients, respectively. On multivariable analysis, only ischemia time associated with AKI occurrence (p1⁄40.016). Based on the proposed criteria, median recovery from ischemia was 99% in patients without AKI and 95%, 90%, and 88% for patients with grades 1/2/3 AKI, respectively. AKI grade based on proposed criteria associated with subsequent recovery (p1⁄40.018), while AKI grade based on standard criteria failed to associate (p1⁄40.5). CONCLUSIONS: Parenchymal mass reduction and ischemia both contribute to acute changes in SCr after PN, however only classification of AKI by proposed criteria, which more accurately reflect the impact of ischemia, associates with subsequent functional recovery. While AKI associated with suboptimal recovery, even patients with grade 2/3 AKI reached 88-90% of recovery expected.

MP41-10 RENAL TUMOR ENUCLEATION MAXIMALLY PRESERVES RENAL PARENCHYMAL VOLUME COMPARED TO STANDARD PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I1 Apr 2016MP41-10 RENAL TUMOR ENUCLEATION MAXIMALLY PRESERVES RENAL PARENCHYMAL VOLUME COMPARED TO STANDARD PARTIAL NEPHRECTOMY Robert H. Blackwell, Belinda Li, Zachary Kozel, Zhiling Zhang, Juping Zhao, Sarah Capodice, Gregory Barton, Arpeet Shah, Jessica Wetterlin, Marcus L. Quek, Steven C. Campbell, and Gopal N. Gupta Robert H. BlackwellRobert H. Blackwell More articles by this author , Belinda LiBelinda Li More articles by this author , Zachary KozelZachary Kozel More articles by this author , Zhiling ZhangZhiling Zhang More articles by this author , Juping ZhaoJuping Zhao More articles by this author , Sarah CapodiceSarah Capodice More articles by this author , Gregory BartonGregory Barton More articles by this author , Arpeet ShahArpeet Shah More articles by this author , Jessica WetterlinJessica Wetterlin More articles by this author , Marcus L. QuekMarcus L. Quek More articles by this author , Steven C. CampbellSteven C. Campbell More articles by this author , and Gopal N. GuptaGopal N. Gupta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.177AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal tumor enucleation is a technique that may facilitate maximal parenchymal preservation, but this has not been rigorously studied. We assess the precision of excision and reconstruction of tumor enucleation compared to standard partial nephrectomy. METHODS Robotic partial nephrectomy patients were included who had appropriate pre- and post-operative studies for analysis of parenchymal mass preservation specific to the operated kidney. CT or MR imaging and eGFR were required to be < 2mo prior to and 4-12 months after surgery. We report parenchymal mass preservation and surgical precision for each technique, with precision defined as the actual postoperative parenchymal volume/predicted parenchymal volume, presuming loss of a 5mm rim of normal parenchyma associated with tumor excision and reconstruction. RESULTS Analysis of 110 patients included 57 tumor enucleation and 53 standard partial nephrectomy. Median age, BMI, and tumor size were comparable, but tumor enucleation had more high complexity tumors by RENAL score (40.4% vs 18.9%, p=0.047). Percent parenchymal mass preserved in the operated kidney with tumor enucleation was 96% (IQR=89.6-100.0%) vs. 89% (IQR=83.3-96.3%) for standard partial nephrectomy (p=0.003). Precision of excision and reconstruction was 101% (IQR=95.5-105.1%) for tumor enucleation compared with 94% (IQR=88.3-100.0%) for standard partial nephrectomy (p<0.001). On multivariable analysis, only tumor enucleation correlated with improved surgical precision (coefficient 6.7, 95% CI 1.6 - 11.8, p=0.01). Functional preservation within the operated kidney also appeared to favor tumor enucleation although the differences were marginal (96% vs. 93%), and statistical significance was not observed (p=0.2). CONCLUSIONS Tumor enucleation maximally spares normal renal parenchyma compared to standard partial nephrectomy, and provides better surgical precision. Prospective study of tumor enucleation will be required to appropriately select patients for this technique. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e563-e564 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Robert H. Blackwell More articles by this author Belinda Li More articles by this author Zachary Kozel More articles by this author Zhiling Zhang More articles by this author Juping Zhao More articles by this author Sarah Capodice More articles by this author Gregory Barton More articles by this author Arpeet Shah More articles by this author Jessica Wetterlin More articles by this author Marcus L. Quek More articles by this author Steven C. Campbell More articles by this author Gopal N. Gupta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP41-09 ASSESSMENT OF SURGICAL OUTCOMES OF THE NON-RENORRHAPHY TECHNIQUE IN OPEN PARTIAL NEPHRECTOMY FOR =T1B RENAL TUMORS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I1 Apr 2016MP41-09 ASSESSMENT OF SURGICAL OUTCOMES OF THE NON-RENORRHAPHY TECHNIQUE IN OPEN PARTIAL NEPHRECTOMY FOR =T1B RENAL TUMORS Toshio Takagi, Tsunenori Kondo, Kenji Omae, Junpei Iizuka, Hirohito Kobayashi, Yasunobu Hashimoto, and Kazunari Tanabe Toshio TakagiToshio Takagi More articles by this author , Tsunenori KondoTsunenori Kondo More articles by this author , Kenji OmaeKenji Omae More articles by this author , Junpei IizukaJunpei Iizuka More articles by this author , Hirohito KobayashiHirohito Kobayashi More articles by this author , Yasunobu HashimotoYasunobu Hashimoto More articles by this author , and Kazunari TanabeKazunari Tanabe More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.176AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renorrhaphy technique is a standard method to adapt renal parenchyma in partial nephrectomy (PN). However, adapting the renal parenchyma into a suitable shape without damaging vessels in cases of large renal tumors located at the renal hilum can be challenging, which has potential to reduce vascularized parenchymal mass. We assessed surgical outcomes between the non-renorrhaphy and renorrhaphy techniques in open partial nephrectomy for ≥ T1b renal tumors using volumetric studies. METHODS We retrospectively analyzed the records of 91 patients with normal contralateral kidneys who underwent both open PN for ≥T1b renal tumors and pre- and postoperative enhanced computed tomography between 2010 and 2014. Volumetric studies to assess vascularized parenchymal volume of the operated kidney were performed within 2 months preoperatively and 6 months postoperatively. Using the non-renorrhaphy technique, hemorrhagic areas on the surface of the renal parenchyma were coagulated by using monopolar soft-coagulation, while a TachoSil® tissue-sealing sheet was placed on the resected bed. RESULTS A total of 50 patients underwent renorrhaphy and 41 patients underwent non-renorrhaphy. Patient backgrounds and R.E.N.A.L Nephrometry scores were not significantly different between the two groups. Cold ischemia time was significantly longer in the renorrhaphy than in the non-renorrhaphy (52min vs. 42min, p=0.0162). However, significant differences were not observed in the preservation rate of the vascularized parenchymal mass in the operated kidney (renorrhaphy,71%:non-renorrhaphy,70%, p=0.5054) and global kidney function (renorrhaphy,88%: non-renorrhaphy,90%, p=0.3653) between the two groups. Age is the only predictor for global kidney function preservation (table). Renal artery pseudoaneurysm occurred in two cases in both groups. Urinary fistula tended to occur more frequently in non-renorrhaphy (2 cases) than in renorrhaphy (5 cases), though this difference was not statistically significant (p=0.237). CONCLUSIONS The non-renorrhaphy technique failed to show a benefit in the preservation of vascularized parenchymal mass of the operated kidney and global renal function for ≥T1b renal tumors compared to the renorrhaphy technique. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e563 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Toshio Takagi More articles by this author Tsunenori Kondo More articles by this author Kenji Omae More articles by this author Junpei Iizuka More articles by this author Hirohito Kobayashi More articles by this author Yasunobu Hashimoto More articles by this author Kazunari Tanabe More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Inflammatory myofibroblastic tumor of the lung in pregnancy mimicking carcinoid tumor

Inflammatory myofibroblastic tumors (IMT) are uncommon neoplasms of the lung in adults. They constitute less than 1% of all lung neoplasms and usually present as parenchymal masses. Diagnosis requires a high index of suspicion. They are characterized by spindle-shaped tumor cells (fibroblasts/myofibroblasts) in a background of lymphoplasmacytic infiltrate. About 50% of the tumors harbor an ALK gene rearrangement. They have to be differentiated from inflammatory pseudotumors (IPT), which show increased number of IgG4 plasma cells on immunostaining and are negative for anaplastic lymphoma kinase (ALK) protein. Herein, we present a case of a 28-year old female who presented with hemoptysis and was diagnosed with an IMT of lung in the first trimester of pregnancy. We have not only reviewed the occurrence of IMT during pregnancy but also discuss the management options for IMT during pregnancy.

Chronic granulomatous mastitis: A therapeutic dilemma revisited

Background: Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease. Because of obscure etiology and diagnosis, its management remains a challenge. Rareness and varied presentation of IGM makes it difficult to standardize treatment protocol. The aim of this study was to analyze the clinical presentations, imaging findings, clinical course, and management of patients who were treated for IGM. Patients and Methods: In this study, a retrospective review of 15 patients with IGM between January 2012 and December 2014 was performed based on clinical, radiological, and pathological findings; follow-up information and recurrence were obtained from records. Results: The median age of presentation was 30 years (age range: 24–42). All patients were married and parous with a history of breast feeding. Breast mass with or without skin changes was a symptom in all patients. While parenchymal heterogeneity, abscess, and mass were the findings of ultrasound, increased asymmetric density was the main finding of mammography. Wide local excision was performed in 7 (46.7%) patients and incisional biopsy with abscess drainage in 4 (26.7%) patients. Medical treatment was given to 4 (26.7%) patients. Median follow-up was 24 (range: 10–34) months. Eleven patients (73%) were recurrence free. Conclusions: Granulomatous mastitis often presents as a breast lump with or without skin changes. The diagnosis is done with pathological examination of the surgical specimen or biopsy. The main treatment should be guided according to the clinical presentation either surgical or medical or both.

Disseminated Abdomino-Pelvic Intraperitoneal Hydatid Disease Presenting as Advanced Ovarian Cancer: A Case Report and Review of the Literature

Abstract Background: Abdomino-pelvic masses with ascites, peritoneal disease, pleural effusion, and elevated serum CA-125 levels in a patient raises the clinical suspicion of advanced ovarian cancer. However, disseminated tuberculosis and echinococcosis are benign conditions that can mimic an ovarian malignancy. This article presents an unusual case of double benign pathology of an ovarian fibroma and disseminated pelvic hydatid disease that appeared to be advanced ovarian cancer. Case: A 57-year-old postmenopausal woman of Peruvian origin presented with a history of abdominal pain, distension, and chronic cough. On examination, she was noted to be cachectic and had ascites. A chest X-ray showed the presence of pleural effusion. Her serum CA-125 level was elevated. Computed tomography (CT) scans of her thorax, abdomen, and pelvis confirmed the right-sided pleural effusion and revealed the presence of adnexal masses, a calcified parenchymal liver mass, and an omental cake. Initial decision was to start on ...

Acute Kidney Injury after Partial Nephrectomy: Role of Parenchymal Mass Reduction and Ischemia and Impact on Subsequent Functional Recovery

BackgroundAcute increase of serum creatinine (SCr) after partial nephrectomy (PN) is primarily due to parenchymal mass reduction or ischemia; however, only ischemia can impact subsequent functional recovery. ObjectiveWe evaluate etiologies of acute kidney injury (AKI) after PN and their prognostic significance. Design, setting, and participantsFrom 2007–2014, 83 solitary kidneys managed with PN had necessary studies for detailed analysis of function and parenchymal mass before/after surgery. AKI was classified by Risk/Injury/Failure/Loss/Endstage classification and defined by either standard criteria (comparison to preoperative SCr) or proposed criteria (comparison to projected postoperative SCr based on parenchymal mass reduction). Subsequent recovery was defined as percent function preserved/percent mass saved. InterventionPN. Outcome measurements and statistical analysisPredictive factors for AKI were evaluated by logistic regression. Relationship between AKI grade and subsequent functional recovery was assessed by linear regression. Results and limitationsMedian duration warm ischemia (n=39) was 20min and hypothermia (n=44) was 29min. Median parenchymal mass reduction was 11%. AKI occurred in 45 patients based on standard criteria and 38 based on proposed criteria, and reflected injury/failure (grade = 2/3) in 23 and 16 patients, respectively. On multivariable analysis, only ischemia time associated with AKI occurrence (p=0.016). Based on the proposed criteria, median recovery from ischemia was 99% in patients without AKI and 95%/90%/88% for patients with grades 1/2/3 AKI, respectively. The coefficient for association between AKI grade based on proposed criteria and subsequent functional recovery was -4.168 (p=0.018). Main limitation is limited patient cohort. ConclusionsParenchymal mass reduction and ischemia both contribute to acute changes in SCr after PN. Classification of AKI by proposed criteria significantly associates with subsequent functional recovery. However, more robust numbers will be needed to further assess the merits of the proposed criteria. While AKI is associated with suboptimal recovery, even patients with grade 2/3 AKI reached 88–90% of recovery expected. Patient summaryAcute decline in function after partial nephrectomy associates with more prolonged ischemia time, and appears to impact subsequent functional recovery. However, most kidneys eventually recover strongly, even if their function is sluggish in the first few days after surgery.